Summary: In June meetings, the House
of Delegates of the American Medical Association (AMA) kicked off an
escalating round of attacks on the advancement of
other healthcare professions. Targeted this year were all disciplines
with doctoral-level training, as well as licensed midwives. Chiropractors, naturopathic physicians and nurses - who cited Wilk v AMA - are among those that have been quick to
challenge the AMA. The
AMA actions are part of that guild's divisive AMA Scope of Practice
Partnership (SOPP), announced in January 2006. Meantime, one action at the
House of Delegates meeting suggests that the snake on the AMA's caduceus may be
biting its own tail. Resolution 235 is an effort to keep the AMA's own specialty societies from legislative actions that seek to restrict each other's scope of practice.

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"Whereas, The economics of medicine have put financial
pressure on all physicians ... "
- from the AMA House of Delegates "Friendly Fire" Resolution 235

The first round of this activity made it clear that the AMA did not make its case against the nursing doctorate, and
against naturopathic physicians and others, based on evidence that
these disciplines have caused harm. This second round of AMA activity
appears to also lack an evidence base.

A
point of clarity made in the
first round is
that
the AMA did not make its case against
the nursing doctorate, and
against
naturopathic physicians and others
based on evidence that
these
other disciplines have caused
harm by their scopes.

This
round of AMA activity appears
to also lack an evidence base.

Below is basic information on the various resolutions in the current
campaign, followed by some of the responses of the professional
associations which the AMA is targeting.

Directly in AMA's sights at the June 2008 meeting were the
"doctor-nurses" - Doctors of Nursing Practice. But all other health
professional practices with doctoral level training were also targeted
by Resolution 232 (formerly Resolution 303). This Resolution, in its original form, would have clarified that only
MDs, dentists and DOs should have any right to be called "doctor" in a
medical setting. Only their fields could use the terms "resident" and "residency." The original
resolution which was under consideration is printed at the bottom of
this article. Notably, Illinois, which introduced the Resolution, is one of the states where
chiropractors have their broadest scope and where naturopathic
physicians are currently pressing for licensing.

Following debate, the AMA's House backed off. They acknowledged, as noted in the "Report of
Reference Committee B" on House action, that "any
individual who has received a terminal degree in their area of study
has the right to be called 'doctor,'" according to a report on what was
clearly a heated debate. The House chose to adopt a milder Substitute Resolution 232, which states that:

RESOLVED, That
our AMA advocate that professionals in a clinical health care setting clearly
and accurately identify to patients their qualifications and degree(s) attained
and develop model state legislation for implementation. (Directive to
Take Action)

RESOLVED,
That our AMA support state legislation that would make it a felony to
misrepresent ones’ self as a physician (MD/DO).

Resolutions #204 and #205 - Against homebirth and keeping an eye on Certified Professional Midwives

Resolution 204, Midwifery Scope of Practice and Licensure, urges the
AMA to ensure that the only midwives its members should support
are those that are represented by the American College
of Nurse-Midwives. Even these, however, should be watched closely regarding their scope expansions. Not mentioned in this section in the report from the House of Delegates are the Certified Professional Midwives
who are trained to provide home births but are not nurses. The opposition
to home birth is reaffirmed in Resolution 205 which is specifically
against "home deliveries."

Resolution #214 - Against the Doctor of Nursing

According to Resolution #214, the National Board of Medical Examiners (NBME)
- the examining board for MDs - has begun "developing a voluntary (Doctor of Nursing Practice-DrNP)
certification exam based on the same exams given to medical doctors to
obtain their medical license." Such a certification would clarify which nurses
might help meet the estimated shortage of 85,000-200,000 primary care
providers. NBME was urged not to assist the nurses. Resolution #214 opposes the NBME "participating in any
credentialing procedures for Doctors of Nursing, and refrain from
producing test questions to certify these DrNP candidates." The Resolution also asserts that DrNPs "must be part of a medical team
under the supervision of a licensed MD who has final authority and
responsibility for the patient."

Resolution 235: Against physicians warring against other physicians

The rationale the AMA offers for these
resolutions is typically protection of the public health,
despite the fact, as noted, that evidence is not presented to show harm. It is
interesting in this light to look at an additional resolution, also
about scope of practice concern. Only here, the target is not nurses, chiropractors, naturopathic physicians, midwives, Doctors of Acupuncture and Oriental Medicine or any other field. It seems that in the midst of this flurry of activity to keep the natives from climbing
the ramparts, the AMA was discovering that some of their fellows had circled the wagons and begun shooting at each other. Resolution 235 may be dubbed the "Friendly Fire" resolution.
According to Resolution 235, members of one
specialty are sometimes deciding that a certain procedure or surgery typically
associated with another specialty is within its possible practice
scope. This then is apparently stimulating some specialties to seek to protect their privilege by running to their
state legislatures to limit the scopes of encroaching
specialties. Resolution 235, printed in full below, begins
with an honest acknowledgment of the economic issues which are behind
all of the activity, of the AMA and of the other, emergent
doctoral-level organizations.

____________________________

The "Friendly Fire" Resolution
#235:Physician Regulation of Other Physicians

AMERICAN MEDICAL
ASSOCIATION HOUSE OF DELEGATES

Whereas, The economics of medicine have put financial
pressure on all physicians; and

Whereas, Some medical specialty societies have elected to
seek the introduction of state level legislation that regulates or restricts
other physicians’ practices; therefore be it

RESOLVED, That our American Medical Association, with the
intent of improving patient care and promoting interspecialty collaboration,
develop a process for national specialty groups to urge their state affiliates
to work through the state medical association prior to the introduction of any
state legislation that seeks to regulate or restrict the practice of other
physician groups or specialties. (Directive to Take Action)

Fiscal Note:Implement
accordingly at estimated staff cost of $10,836.

Received:06/10/08

____________________________

1. Response of the American Association of Naturopathic Physicians

The American Association of Naturopathic Physicians (AANP)
sent a news update to their members prior to the AMA's action entitled "AANP Response to
AMA Resolution 303." (Note that 303 was later passed as 232 and significantly amended.) The AANP letter begins
bluntly: "The American Medical Association is
poised to make a move that could
have a huge impact on our ability to call ourselves Naturopathic
Doctors." The AANP noted that Resolution 303 "ignores laws already on the books" and it
"discounts federal standards." The AMA is "creating a national agenda
to ensure the current hierarchy in health care is maintained -
regardless of a shortage of primary care practitioners, the obvious
need to transcend from disease management to a wellness-based system,
and the rising numbers of consumers who are choosing non-conventional
treatment."

The AANP's letter, signed by president Lise Alschuler, ND, NABNO,states that the
AMA's moves will "only serve to unfairly penalize legitimately trained
providers of primary care services from practicing their trades." The letter then underscores that this agenda is "deeply rooted in
an old story and worldview that simply does not reflect today's
reality" in which "MDs, NDs and nurses already work side by side,
collaborating on patient care in venues across the country."

Note: I have not seen AANP commentary since Resolution 303 was changed and
amended. However, the profession clearly asserts the right to be
considered "physicians" and also have this as a title right in many
jurisdictions.

2. American Chiropractic Association Response
The American Chiropractic Association sent out a press release against Resolution 232 on June
21, 2008, after the AMA House of Delegates concluded its meeting.
The ACA states that "under federal statute, all doctors of chiropractic are
considered physicians in Medicare and doctors of chiropractic are legally
deemed chiropractic physicians in an overwhelming majority of states." Glenn Manceaux, DC, ACA president is quoted:
“It is not the role of organized medicine to regulate the titles and
terminology used by other providers; it is the responsibility of federal and
state legislators to bestow the title of ‘physician.’ As a trade
association, the AMA is clearly overstepping its bounds.”

The ACA statement makes two points also made by the AANP, regarding the role of consumers and the potential damage to the growing number of professional relationships that currently exist between their members and
medical doctors. The release states: "Within the chiropractic profession, concern also exists that supporters of
the resolution are acting in their own self-interest at the expense of
consumers, and that the new policy statement could jeopardize the
inter-referral relationships many allied health providers—including doctors
of chiropractic—have developed with their MD-counterparts."

ACA, known for its legislative successes against the organized
medical profession, urges its state associations to be vigilant. The organization notes that it will be working with two separate coalitions to see that
any AMA-backed legislation related to Resolution 232 does not advance.

3. Nurses Respond to #303 and #214

In
separate letters on June 11, to Craig Anderson, MD, chair of the
AMA committee which oversaw the resolutions, the American Nurses
Association opposed Resolution #214 and #303. On #303, the ANA made
the point, which eventually prevailed (and which the AANP also made), that no
profession owns the title "doctor." Hence, they state, the term "medical doctor"
was created, to designate what types of doctor. Ditto "medical resident" and
"medical residency."

The nurse association then evoked that AMA's most significant loss in its efforts to repress other professions: Wilk v. AMA - in which the chiropractic profession won a 10-year long restraint of trade battle. Said the nurses:

"If the real issue is competition, and this is an effort to make it more difficult for doctorates of nursing to train and practice in the same arena as medical doctors, that would constitute an improper - and possibly illegal - restrain of trade. In Wilk v. AMA, the US Court of Appeals for the 7th Circuit ruled that the AMA cannot "boycott" other healthcare professions, as this would violate the Sherman Antitrust Act. (Wilk v. AMA, 895 F. 2d 352 (7th Cir. 1990)

The opposition to #214 particularly focused on the requirement for
supervision by an MD: "State law, state boards of nursing, and the
nursing profession itself are the only appropriate entities to regular
the practice of nursing." (The American Chiropractic Association made a
parallel point.) The ANA clarified further its own Copernican
revolution regarding the center of the medical universe: "The medical
profession is not the 'starting place' from which all other professions
must seek authorization to practice."

In the letter - both were co-signed by Rebecca M. Patton, MSN, RN, CNOR,
the ANA's president and Linda Steele, MSN, RN, CNAA, BC, CEO -the ANA
points to a 2007 document, developed collaboratively by representatives
of six disciplines, including both nursing and medicine, entitled Changes in Healthcare Professions Scope of Practice: Legislative Considerations.
The report noted that "it is no longer reasonable to have completely
unique scope of practice, exclusive of all others. Overlap among
professions is necessary. No one profession actually owns a skill or
activity in and of itself."

________________________________________

AMERICAN MEDICAL
ASSOCIATION HOUSE OF DELEGATES

Resolution 232 as Introducted

[NOTE THAT IT WAS NOT ADOPTED IN THIS FORM]

Introduced by:Illinois
Delegation

Subject:Protection
of the Titles "Doctor," "Resident" and
"Residency"

Referred to:Reference
Committee B(Craig
W. Anderson, MD, Chair)

Whereas, Certain specialty societies recognize that many
allied health care professions have improved their educational standards and
incorporated doctorate designations in their training programs; and

Whereas, Many nursing schools have re-titled their training
program as a Residency and their students as Residents, despite the traditional
attribution of these titles to medical doctors and their training programs; and

Whereas, The growing trend of this title encroachment is of
concern because patients will be confused when the titles of Doctor, Resident
and Residency are applied to non-physicians who hold non-medical doctorates or
to non-physicians in training; therefore be it

RESOLVED, That our American Medical Association adopt that
the title “Doctor,” in a medical setting, apply only to physicians licensed to practice
medicine in all its branches, dentists and podiatrists (New HOD Policy); and be
it further [NOTE: iN DISCUSSION

RESOLVED, That our AMA adopt policy that the title
“Resident” apply only to individuals enrolled in physician, dentist or
podiatrist training programs (New HOD Policy); and be it further

RESOLVED, That our AMA adopt policy that the title
“Residency” apply only to physician, dentist or podiatrist training programs
(New HOD Policy); and be it further

RESOLVED, That our AMA serve to protect, through
legislation, the titles “Doctor,” “Resident” and “Residency.” (Directive to
Take Action)

Fiscal Note:Staff
cost estimated at less than $500 to implement.

Received: 04/30/08

_______________________________

Comment: One wonders if these leaders of the Illinois Delegation, and of the AMA
House of Delegates, truly believe that they can set back the clock.
The cows are already out of the barn. And there are millions of
consumers who clearly like them there. Many politicians and policy makers believe these professions have significant roles to play, for instance, in easing the primary
care shortage.

I have long argued that all
of the distinctly
licensed
complementary healthcare
disciplines owe the chiropractors
a
deep debt of gratitude for Wilk.

But I never imagined that the
chiropractors' victory would one day
be used by the nurses.

It is fascinating, in this context, to note some rifts inside the fabric
of organized medicine. First, Resolution 303 was not passed. The
House woke up the the plain fact that, as was said in the final report
of House action to the AMA, "any individual who has received a terminal
degree in their area of study has the right to be called 'doctor.'"
Yet the item still made it onto the agenda, attesting to the hold this repressive concept still has.

Second, the National Board of Medical Examiners - the MD examining agency - apparently thought it within its mission to enter into dialogue with
the nursing profession on that profession's examination needs. How will NBME respond to this slap? How responsive will the NBME, a nominally independent entity, be to the AMA pressure?

Non-allied health

On the other hand, parallel positions of chiropractors, nurses and naturopathic physicians underscores the depth of shared interest in the Coalition for Patients Rights. Finally, the nurses' use of Wilk v. AMA drives home just how powerfully mis-allied the AMA is, on this issue, from what used to be known as the "allied health" disciplines. I have long argued that all of the distinctly licensed complementary healthcare disciplines owe the chiropractors a deep debt of gratitude for Wilk. But I never imagined that the chiropractor's long battle would be cover for the nurses.

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